ST ELIZABETH

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed a total of 7 quality statements from this key question. We have combined the scores for these areas with scores based on the rating from the last inspection, which was good. Our rating for this key question had deteriorated to inadequate. We found the provider was failing to meet their legal requirements and were in breach of 4 legal regulations. We identified significant and widespread concerns in respect of people’s safe care and treatment, safeguarding and staffing and fit and proper persons employed. The provider failed to ensure individual and environmental risks to people were appropriately identified, assessed and managed. People’s medicines were not always safely managed, and the provider did not ensure people were supported by staff who had the relevant skills, knowledge and training to meet their needs. The providers recruitment practices were not in line with requirements to ensure they followed safe recruitment processes when new staff were employed. The providers safeguarding systems and processes were ineffective, and we were not assured that people were always appropriately protected from the risk of avoidable harm. The provider did not operate systems and processes to learn from safety events or incidents at the service to improve the quality of care for people. We observed shortfalls in the infection control practices of the home and processes were not robust to protect people from the risk of infection.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Overall people felt staff listened to them and that they could raise any concerns. However, relatives felt communication needed to be improved when things go wrong. For example, one relative said, “We definitely need better feedback to us after problems.”.

Staff and leaders were not able to demonstrate any evidence of how lessons were learnt to continually identify, improve and embed new practices. Leaders of the service told us this was an area that needed to improve.

There provider failed to demonstrate they had embedded effective processes to identify, monitor and promote learning from events at the service. There were no formal processes in place to ensure identified learning from events was consistently shared with staff. We reviewed audits completed by the manager where events at the service had occurred which included falls, accidents and incidents and found these were not robust. For example, where some people had experienced multiple falls, processes in place were not effective or robust to ensure appropriate consideration was given to review mitigating factors or identify possible patterns, themes and trends. The manager told us they shared lessons learnt with staff verbally, however they were unable to provide any evidence where learning had been identified, shared and embedded in practice to improve outcomes for people using the service.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People we spoke with told us that there were no restrictions on their care for example, they could go to bed and get up when they wanted to. We received feedback from relatives that they felt their loved ones received safe care.

Staff we spoke with understood how to raise and report safeguarding concerns to senior leaders. However, staff were not aware how they could contact other organisations outside of the home such as the local authority who are responsible for safeguarding adults at risk in their area. A staff member also told us, “When something is reported it doesn’t get looked into straight away, there have been times I have to keep asking are you going to check?, or, maybe you should call a doctor?, but I feel like what I say just goes over [leaders] head’s.” Some people at the service were subject to a deprivation of liberty authorisation. Staff we spoke with were unsure which residents had this in place.

We were not assured that people were always appropriately protected from the risk of harm. For example, during this assessment we observed an example where a person who was cared for in bed was unable to seek support from staff. We observed the person calling for staff assistance and they told us they were experiencing pain and discomfort. The person was unable to use their call bell as this was faulty. We reviewed records and spoke with staff and identified this was a known issue. The provider had failed to ensure that sufficient monitoring had been implemented or that timely action had been taken to resolve this issue. We raised this with the registered manager who took action to address this.

We found significant shortfalls in the providers safeguarding processes. Systems for safeguarding people were not effective. We were not assured leaders always took action or consistently shared the required information with the local authority to ensure people were protected from the risk of harm. Where information of concern was raised, we were not assured timely investigations or actions were always taken where this was required to protect people from the risk of harm. The provider’s safeguarding policy was out of date and did not reflect their current legislation requirements. The policy also failed to include details of which organisation staff should contact to escalate concerns such as the local authority safeguarding teams. During this assessment we identified evidence whereby people were at risk of or experiencing harm and or abuse. Due to the providers lack of process, we shared our concerns with the local authority. We were not assured the provider consistently met their legal requirements where people were deprived of their liberty. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We found examples where the provider failed to make the required application to the authorising body where people were unable to consent to their accommodation.

Overall People told us that they felt staff were good at keeping them safe and they were supported to be as independent as possible.

We were not assured all staff were fully informed of people’s needs or how to manage risk in line with people’s care plans. For example, we spoke with staff about people's prescribed modified diets and found some staff lacked the sufficient understanding of how each person required their meals prepared to manage the risk of choking and dysphagia. We also received conflicting information from staff about people’s needs and how they should prepare certain foods to minimise risks. Staff told us they were informed of changes to people’s needs through handover information, however one staff member commented that they did not always get time to read through people’s risk assessments, another staff told us information in care plans to manage risk is “not enough really.” and another staff member said, “I commented on the care plans before as I felt there’s was stuff missing but I got over looked.”.

During our assessment we observed shortfalls in how people were supported to safely manage risk. For example, we observed a person was provided with food items for their meal that was not in-line with their prescribed modified diet. We also observed an agency member of staff use an approach to assist a person from a seated to standing position using their hands which is not in line with best practice guidance. Where a person had a risk assessment in place to outline the requirements for a clutter free environment to reduce the risk of falls, we observed their bedroom did not reflect this and was not free from clutter or potential trip hazards. Therefore, we were not assured that people were consistently supported to mitigate and manage the risk of avoidable harm.

We found significant and widespread shortfalls in the providers risk management processes. We were not assured people consistently received safe care and treatment. For example, risk management plans were not always in place, robust or contemporaneous to reflect the care people required. These included risks associated with thickened fluids being prepared and given, and inconsistent records and management of people's dietary needs to manage the risk of choking and dysphagia where they had a prescribed modified diet. We found significant shortfalls in people’s repositioning records and the provider could not demonstrate that people had been supported with repositioning in the time frame they had been assessed as needing to maintain their skin integrity. Care records for people who had specific conditions such as Asthma, Parkinson's disease and Diabetes were not sufficiently detailed or robust to ensure staff had all the information they required to safely meet their needs. For example, where a person has a diagnosis of Parkinson’s disease and were prescribed medicines for symptom control, there was no specific care plan or risk assessment in place to support and guide staff around the importance of time sensitive medicines. There were no detailed care plans or risk assessments in place for people who had medicine allergies or who were prescribed laxatives PRN to prevent constipation. For example, the provider failed to ensure that risk management plans were in place to mitigate the risk of constipation and impaction where people were assessed to require support to manage their elimination or who were prescribed laxatives when required (PRN) to prevent constipation.

Some people told us that they felt the service was well maintained, however other people told us improvements were needed. Feedback we received included poor décor, holes in the walls and a person told us it made the feel “depressed.” Some relatives commented that facilities in the home needed to be improved. For example, relatives commented that their loved ones were not able to access reclining chairs in the lounge as the equipment available was broken. Comments included, “[Staff] keep saying they will replace [chairs] but never do”, “So much is broken here.”

Staff and leaders were not always clear of their responsibilities in relation to compliance with health and safety requirements. For example, the maintenance staff delegated the task of assessing the window restrictors and the manager was not able to tell us what the requirements were. In respect of required water temperature checks, both the maintenance staff and manager were not able to tell us what the safe ranges were for water temperatures. This placed people at potential increased risk of harm due to lack of staff knowledge.

We made some observations during the assessment that the environment was not always safe. For example, we observed wardrobes that had not been appropriately fixed in place which placed people at the risk of injury. We also observed that the provider had failed to ensure window restrictors were in place on most of the windows that required them within the home, such as, bedrooms, bathrooms and communal areas at ground floor and 1st floor level. This meant we were not assured that people were always appropriately protected from environmental risks.

We found significant and widespread shortfalls in the safe management of the environment. We were not assured the provider undertook appropriate measures to ensure people, staff and visitors accessing the building were appropriately protected. Examples included failure to ensure people were appropriately protected against the risk of legionella. Legionella is a bacterium that can cause a severe type of pneumonia (legionnaires disease). The provider did not ensure there was an appropriate risk assessment or policy in place to ensure staff knew what their legal requirements were and how to manage the risk of legionella. Shortfalls we found included the failure to operate effective systems to ensure accurate recordings of water temperatures were taken, failure to ensure that annual servicing of the thermostatic mixing valves was undertaken and ineffective oversight where these tasks were delegated. The provider failed to ensure the home environment was safe by assessing and reducing risks related to fire. Shortfalls included failure to ensure up to date and robust risk assessment of fire, gaps in required fire safety equipment checks and regular fire drills had not taken place to adequately prepare staff for a potential fire. Where we identified significant concerns around fire safety at this assessment, we shared our findings with the appropriate fire and rescue service. The provider failed to ensure regular testing and servicing of equipment was undertaken in-line with the requirements. For example, electrical wiring tests were 2 years overdue, and they failed to ensure annual gas safety checks had been completed. The provider also failed to ensure timely servicing and repair of equipment was undertaken in respect of moving and handling equipment used to support people’s bathing.

People we spoke with told us that there were not enough staff, and a person commented that they have had to wait a long time when they had fallen for staff to “find them”. People told us that the staff were kind but seem rushed and didn’t always have time to spend with people, one person told us they felt neglected. People told us that they were supported by a lot of agency staff, particularly at the weekend, and that they felt these staff didn’t always know people well. Feedback we received included, “I’m getting better at standing up for myself, you have too in here” and “Today I had to go to the toilet on my own as there was no one to help. We were left alone in the lounge, I’m so frustrated here, no one does what they say” and “They have had lots of staff problems.” Some people told us that their call bell was answered promptly, however some people said that they had to wait a long time. Feedback included, “They sometimes take a while to answer my bell” and “The call bells can take up to 20 mins if they’re busy.”.

We received mixed feedback from staff on whether they felt staffing was sufficient. Some staff told us they felt there were enough staff on duty to meet people's needs. However, other staff comments included, “At times staffing is a struggle, 2 is enough at night but not in an emergency” and “We are very short staffed, I have worked when there is just me and a team leader on shift, we didn’t get to have a break. There is definitely not enough staff, we have had some really good staff member’s but they left due to bullying.” We spoke with the registered manager about staff training requirements, and they told us they were aware that this was an area that needed to improve. A staff member commented, “I do think we need more training when it comes to feeding the residents. I’ve seen a staff member force a spoon into someone’s mouth because they refused.” And another staff member said, “[I] had asked the previous manager for updated training, but it didn’t happen.” Leaders of the service were aware of the shortfalls in the recruitment processes at the service. The registered manager told us they were unable to locate a number of documents required to demonstrate that safe recruitment practices had been undertaken for most of the staff. This was an area they said they were working on; however, this had not been completed at the time of our assessment.

During our on-site assessments we observed that staff did not always demonstrate they were sufficiently skilled or trained in their requirements of safe management of controlled medicines. For example, a staff member was observed stood in the lounge for 4 minutes with a controlled medicine in their hand whilst waiting for another staff member to act as a witness. We observed the staff member had dispensed this medicine alone, and the staff member who witnessed the administration had not completed the required training to support his task. This was not in-line with best practice guidance. We completed multiple on-site visits to the service during this assessment and observed times where staff appeared to be rushed or deployment of staff was ineffective. We made observations of communal areas and found staff had very little time to provide meaningful engagement with people and people in communal areas were observed to have little opportunities for interaction.

The provider’s recruitment processes were not effective. We reviewed 5 staff recruitment records and found significant shortfalls. This included where staff had worked in care previously, the provider failed to obtain satisfactory evidence of conduct in all relevant roles and reason for leaving. Disclosure and Barring Service (DBS) checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions. Due to the limited information available in staff files we were not assured that all staff had received their full DBS check back prior to commencement of employment. Where the provider used support from agency staff to cover shifts, we found the provider failed to demonstrate how they assured themselves on the suitability of agency staff as they did not always undertake appropriate due diligence. We were not assured staff received all training relevant to their role and training records identified significant and widespread shortfalls. Examples included ensuring staff were suitably trained and skilled to support people with specific conditions such as Parkinson's disease and Epilepsy, and shortfalls in training for staff who had specific roles or who undertook delegated tasks such as maintenance and housekeeping. Where staff were carrying out care tasks to support people, we were not assured that all staff had completed appropriate competency checks in areas relevant to their role, for example, when supporting people with moving and handling. Where staff were new to the service, the provider failed to demonstrate staff were supported through a robust induction. The provider used a staffing dependency tool to support them to calculate the required levels of staffing people needed to meet their needs. We reviewed 3 weeks of staffing rotas and found staffing levels did not always reflect the calculated staffing levels the provider had assessed were required.

We received mixed feedback from people about the cleanliness of the home. Some people told us that their rooms were cleaned regularly, however others felt improvements were needed. Comments included, “There’s no bin in my room, I’ve been asking for the whole time.”, and “Have you seen the mess in this place, its piled everywhere.”.

Staff we spoke with had a basic understanding of the personal protective equipment they could use when carrying out personal care. Staff were unsure when they last completed infection control training. We spoke with a member of housekeeping staff who told us they had not had recent training and raised concerns around the management of housekeeping tasks oversight at weekends.

During the assessment we observed 2 staff members blowing on people’s food to cool it down during lunch time. We also observed poor cleanliness throughout the home, including furnishings, chairs, floors, toilets, and corridors. There were areas of the home that had visible cobwebs at high points and hallway carpets were found to have large stains. A bath seat in the ground floor bathroom had a buildup of grime under the seat and areas of rust where the paint had come off.

We could not be assured that systems to prevent and control infection were robust or effective. There were concerns with infection control within the home. There were areas of the home that were not clean. There was visible dust on some surfaces and cobwebs at high points. The providers infection control policy lacked detail. For example, the policy did not reference how to manage an infectious outbreak and did not include information on acute respiratory infections/Covid-19. There was no information to inform staff on steps they should take to minimise or manage an outbreak including information on control measures, testing, ventilation, and risk assessments. We reviewed cleaning schedules which demonstrated incomplete and inconsistent records. There were shortfalls in Infection control training for staff. Out of 24 staff, 16 staff did not have infection prevention and control training and 20 did not have control of substances hazardous to health (COSSH) training which included 2 housekeepers. We found several boxes of face masks that were out of date. Despite our feedback at the first site visit, when we returned to the service, we found these face masks were still in the premises and available for staff to use.

Overall, people we spoke with said that they received their medicines as they needed the. They also stated that they could ask for ‘When required’ medication and that staff supported this.

Leaders explained how and where they would search for more information about residents' medicines. They were aware that patient information leaflets (PILs) were not being received with the medicines supplied in multi-compartment containers. However, that had not resolved the lack of PILs. When this was fed back to leaders, they agreed to obtain access to the PILs. Leaders were aware of some risks people’s medicines posed, such as people who were prescribed anti-coagulants. Medicines in original packs had "dates opened". However, leaders were not aware that people’s inhalers had revised expiry dates once in use. Leaders told us they recorded people’s topical medicines administration in different records. This meant that there was no consistency in records kept, following our feedback leaders told us they would review this. During our discussions with leaders we were not assured the service was assessing, monitoring or improving medicines optimisation within the service.

We were not assured that medicines were always stored safely. We observed the medicines room unlocked and open with no available key to lock this from the outside to prevent people or staff from accessing these medicines inappropriately. We also found some examples where people’s prescribed medicines were left out and accessible to people. This included 2 pots of thickening powder, which poses a significant choking risk to people if ingested. We also found the provider failed to ensure all medicines including controlled drugs were always securely stored. For example, we found medicine keys were left in the locks of the cabinets during our assessment. ‘When required’ (PRN) medicines administration protocols were not always in place, sufficiently detailed or robust to ensure staff had all the required information to support people’s medicines safely. These included medicines prescribed for people’s respiratory needs, anxiety, and pain relief. Whilst fridge and room temperature records were kept, the recordings did not include the minimum and maximum temperatures, giving no assurance that medicines were consistently stored at the correct temperature. We were not assured all staff were sufficiently trained or had been assessed as competent to undertake medicines administration tasks. For example, we found staff were witnessing controlled drug administration without having the training or the competencies to do so. There were no Emollient risk assessments and management plans in place for people who were prescribed topical creams, where these creams are identified to be highly flammable. The administration of medicines was recorded within the medicines administration record (MAR). Peoples MAR’s included their photograph, details or allergies and intolerances and how they preferred to take their medicines.